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May 3, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.
This Week’s Featured Articles
Njoku A, Evans M, Nimo-Sefah L, et al. Healthcare. 2023;11:438.
Maternal morbidity and mortality are disproportionately experienced by persons of color in the United States. The authors of this article present a socioecological model for understanding the individual, interpersonal, organizational, community, and societal factors contributing to Black maternal morbidity and mortality. The authors outline several recommendations for improving care, including workforce diversification, incorporating social determinants of health and health disparities into health professional education, and exploring the impact of structural racism on maternal health outcomes.
Ude-Okeleke RC, Aslanpour Z, Dhillon S, et al. J Pharm Pract. 2023;36:357-369.
Older adults are particularly vulnerable to medication-related safety events. This systematic review including 21 studies on medication-related problems in in older adults identified several types of safety issues (e.g., potentially inappropriate prescribing, polypharmacy, adverse drug reactions) that lead to poor outcomes among older adults in nursing homes, inpatient care, and community settings. The authors found the classes of medication related problems are similar to studies from a decade ago, suggesting that more intensive monitoring is needed.
Zaranko B, Sanford NJ, Kelly E, et al. BMJ Qual Saf. 2023;32:254-263.
Poor nurse staffing has long been recognized as a patient safety issue. This analysis of three UK National Health Service hospitals examined the differences in in-hospital deaths among different nursing team sizes and compositions. Researchers identified higher inpatient mortality with higher nurse staffing and seniority levels (i.e., more registered nurses [RNs]) but no changes in mortality related to health care support workers (HCSW). Authors surmised that HCSWs may not be a substitute for RNs.
Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;Epub Apr 11.
Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.
Ahmed FR, Timmins F, Dias JM, et al. Nurs Crit Care. 2023;Epub Apr 1.
Staffing shortages are temporarily alleviated with floating or redeployed staff. This qualitative study of intensive care unit (ICU) critical care nurses and floating non-critical care nurses sought to identify the pros and cons of floating nurses, and strategies to improve patient safety. Floating nurses reported concerns surrounding unfamiliarity with the types of patients or locations of equipment. Critical care nurses reported cognitive overload with doing their routine duties plus orienting floating nurses. One recommendation to improve safety is competency-based nursing curriculum and provide floating nurses occasional training/experience in the ICU.
Sands KE, Blanchard EJ, Fraker S, et al. JAMA Netw Open. 2023;6:e238059.
Changes in healthcare delivery due to the COVID-19 pandemic raised concerns about increases in healthcare-acquired infections (HAIs). This cross-sectional analysis of more than five million hospitalizations between 2020 and 2022 found that the incidence of HAIs was higher among patients hospitalized with COVID-19 compared to patients hospitalized without COVID-19.
Krevat S, Samuel S, Boxley C, et al. JAMA Netw Open. 2023;6:e238399.
The majority of healthcare providers use electronic health record (EHR) systems but these systems are not infallible. This analysis used closed malpractice claims from the CRICO malpractice insurance database to identify whether the EHR contributes to diagnostic error, the types of errors, and where in the diagnostic process errors occur. EHR contributed to diagnostic error in 61% of claims, the majority in outpatient care, and 92% at the testing stage.
Larimer C, Sumner V, Wander D. Nutr Clin Pract. 2023;Epub Apr 19.
Medical lines, such as intravenous (IV), oxygen, or feeding tubes, provide lifesaving support but may also pose safety threats. Following a 2022 Food and Drug Administration safety communication regarding risk of strangulation by feeding tubes, researchers sought to determine if pediatric healthcare providers and caregivers were aware of the risk of medical line entanglement, and what, if any, type of education was provided to reduce the risk. Most providers were aware of the risk of entanglement, and 90% of caregivers reported their child had become entangled. However, less than 10% of caregivers received training to prevent such entanglements. Numerous comments from caregivers are provided, describing instances of entanglements and strategies they’ve used to prevent it.
Lyell D, Wang Y, Coiera E, et al. J Am Med Inform Assoc. 2023;Epub Apr 18.
Patients and healthcare providers rely on devices that use artificial intelligence or machine learning in diagnostics, treatment, and monitoring. This study utilizes adverse event reports submitted to the FDA's Manufacturer and Use Facility Device Experience (MAUDE) database for machine learning-enabled devices. Mammography was implicated in 69% of reports, and the majority were near-miss events.
Zaranko B, Sanford NJ, Kelly E, et al. BMJ Qual Saf. 2023;32:254-263.
Poor nurse staffing has long been recognized as a patient safety issue. This analysis of three UK National Health Service hospitals examined the differences in in-hospital deaths among different nursing team sizes and compositions. Researchers identified higher inpatient mortality with higher nurse staffing and seniority levels (i.e., more registered nurses [RNs]) but no changes in mortality related to health care support workers (HCSW). Authors surmised that HCSWs may not be a substitute for RNs.
Beiboer C, Andela R, Hafsteinsdóttir TB, et al. Nurse Educ Pract. 2023;68:103603.
Myriad factors contribute to missed nursing care including staffing, team and group norms, and teamwork. Nurses in this study described four themes that contributed to missed nursing care: teamwork in nursing wards; informal teaching and communication; influence of formal and informal leaders; and influencing factors in nurses’ work environment. Developing nurses' clinical leadership skills may improve teamwork and reduce missed care.
Ward CE, Taylor M, Keeney C, et al. Prehosp Emerg Care. 2023;27:263-268.
Weight-based calculation errors and lack of weight documentation can lead to medication errors in pediatric patients. This analysis of Maryland emergency medical services (EMS) data including children who received a weight-based medication found that weight documentation was associated with a small but significantly lower rate of medication dose errors, particularly among infants and for epinephrine and fentanyl doses.
Basger BJ, Moles RJ, Chen TF. BMC Geriatr. 2023;23:183.
Potentially inappropriate medications (PIM) and polypharmacy, defined as taking 5 or more medications, can increase the risk of hospitalization and other adverse events for older adults. This article describes the implementation and success of a patient-centered medication review conducted at the time of hospital discharge. Nearly all patients followed up with their general practitioner on the pharmacist’s recommendations and approximately three-quarters were implemented. Including the patient and/or caregiver was a key component of the intervention.
Myers E, Allen C. Patient Saf. 2023;5:62-63.
Event reporting is core to identifying system-level problems that could harm patients. This article shares several instances of learning from event reports submitted in the state of Pennsylvania to illustrate the value of reporting in patient safety.
Njoku A, Evans M, Nimo-Sefah L, et al. Healthcare. 2023;11:438.
Maternal morbidity and mortality are disproportionately experienced by persons of color in the United States. The authors of this article present a socioecological model for understanding the individual, interpersonal, organizational, community, and societal factors contributing to Black maternal morbidity and mortality. The authors outline several recommendations for improving care, including workforce diversification, incorporating social determinants of health and health disparities into health professional education, and exploring the impact of structural racism on maternal health outcomes.
Liberman AL, Wang Z, Zhu Y, et al. Epub Apr 5. 2023.
Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors using existing databases, such as electronic health records or administrative claims. The original developers of the SPADE framework provide additional guidance on types of comparator groups, how to select the appropriate group, and what inferences can be drawn from the analysis.
Pitts CC, Ponce BA, Arguello AM, et al. Ann Surg. 2023;277:756-760.
Overlapping surgery – when surgeons schedule distinct procedures on different patients concurrently – has raised safety concerns but recent studies have not found significant differences in perioperative outcomes. This retrospective cohort study including over 87,000 surgical cases found that overlapping surgeries increased operative times but did not lead to increased in-hospital mortality, adverse events, or readmission rates when compared to nonoverlapping cases.
Ude-Okeleke RC, Aslanpour Z, Dhillon S, et al. J Pharm Pract. 2023;36:357-369.
Older adults are particularly vulnerable to medication-related safety events. This systematic review including 21 studies on medication-related problems in in older adults identified several types of safety issues (e.g., potentially inappropriate prescribing, polypharmacy, adverse drug reactions) that lead to poor outcomes among older adults in nursing homes, inpatient care, and community settings. The authors found the classes of medication related problems are similar to studies from a decade ago, suggesting that more intensive monitoring is needed.
Subbe CP, Hughes DA, Lewis S, et al. BMJ Open. 2023;13:e065819.
Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value.
International Meeting/Conference
Clinical Human Factors Group. May 16, 2023, 9:00 AM--12:30 PM (eastern).
Organizations and individuals learn by considering how humans interact while performing routine tasks. This seminar will examine the opportunities for improvement in examining what work-as-done efforts reveal, embedding human factors design considerations into daily work processes, and prioritizing front-line staff experience as a component of safety.
Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2023. AHRQ Publication No. 23-0025.
Burnout reduction in primary care is critical to patient safety. This resource is designed to help practices assess the causes of burnout in primary care and implement strategies to promote well-being. Suggested areas of focus include the reduction of documentation tasks, use of huddles and peer support.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;23(9):1-3.
Psychological safety is required for clinicians to ask questions as they adjust to working in new teams and environments. Part 1 of this article examines the cultural qualities enabling safe onboarding of new practitioners that encourage asking for assistance when uncertainty arises. Recommendations to encourage new hire questioning include mentor programs and scheduled supervisor conversations. Part 2 discusses the role of simulation to build skills in new staff to ensure medication safety.
Book/Report
Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient Safety; April 2023.
Collective engagement and focus are required to attain large system change. This plan centers on five goals to improve patient safety in Massachusetts: leadership and culture, operations and engagement, patient and family support, workforce wellbeing, and measurement and transparency. The document provides guidance for implementation of strategies targeting each goal to generate sustainable improvements.
Newspaper/Magazine Article
Muoio D. Fierce Healthcare. April 21, 2023.
Notable problems have occurred during the testing of the new electronic health records (EHR) system being designed for use in Veterans Affairs hospitals. This news article discusses the temporary halt of the project as the Department reassesses issues that have arisen during test rollouts in several United States hospitals.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Commentary by Michael Leonardo Amashta, MD, and David K. Barnes, MD, FACEP |
This case involves a procedural sedation error in a 3-year-old patient who presented to the Emergency Department with a left posterior hip dislocation. The commentary summarizes the indications and risks of procedural sedation in non-surgical settings and highlights the value of implementing system-wide safety protocols and practices to prevent medication administration errors during high-risk procedures.
WebM&M Cases
Charleen Singh, PhD, MSN/ED, FNP-BC, CWOCN, RN and Brent Luu, PharmD, BCACP |
This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical amputation of the patient’s left fourth (ring) finger. The commentary discusses the importance of correctly identifying IV fluids as irritants or vesicants, risks associated with the use of vesicants such as calcium chloride, and the role of early recognition of infiltration and extravasation and symptom management to minimize tissue damage and accelerate healing.
WebM&M Cases
Spotlight Case
Barbara Resnick, PhD, CRNP, and Marie Boltz, PhD, CRNP |
This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors for falls should be considered in care planning and approaches to fall prevention in long-term care settings.
This Month’s Perspectives
Annual Perspective
Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD |
Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.
Interview
Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.
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